Hallucinations by Oliver Sacks

Reality: Skin deep and is it really skin?

At any given waking moment, most of us live our lives secure in the understanding that what we see, hear, taste, touch and smell corresponds to what is really there—that the apple in the hand, the sunset in the sky, or the oncoming headlights are real things. We eat the apple, appreciate the sunset, avoid the approaching vehicle.

The world that we perceive and with which we interact behaves in ways that agree, mostly, with our perceptions. Even if we wondered—as everyone probably does, sooner or later—whether we can prove that the perceived world is actually there and not just some elaborate figment of the perceiving mind, we can behave as if it is really there. Most of the time, that behavior rewards us with affirmation.

But what if the perceiving end of the arrangement breaks down? What if you sometimes see people no one else sees? What if crowds of silent children constantly appear to be parading through the room, gesturing with pale hands? What if your field of vision fills with shifting geometric shapes…or with the image of a crossbow that turns into arrows that turn into stars that turn into flakes of snow? What if, suddenly, whole pages of imaginary musical notation leap, unbidden, into sight?

And what if friends and family suddenly become strangers—people who look the same as they always did, yet somehow differ, as if aliens inhabited their bodies?

In short, what if you discovered your perception of reality no longer corresponded to the reality everyone else perceives?

You might think you were going crazy.

Maybe you’re not.

It seems the mind can play devious tricks on itself—even when it’s sound, sober and sane.

So says Dr. Oliver Sacks in Hallucinations. This latest installment of brain science for laymen—a genre in which Sacks holds a preeminent place—once again draws on Sacks’ decades as a neurologist who has applied boundless curiosity and a sensitive ear to the strange stories he hears from his patients.

From his best-seller, Awakenings, the 1973 book (and 1990 movie) about the startling transformations that L-dopa could induce in catatonic Parkinson’s patients, to The Man Who Mistook his Wife for a Hat and Musicophilia, Sacks has guided non-scientist readers through obscure corners of the cerebral labyrinth and into underlying truths about the human condition. Some call his field “neurological anthropology.”

In Hallucinations, Sacks offers what he calls “a sort of natural history or anthology of hallucinations,” describing their impact on the people who have them, and relying largely on first-person accounts to convey the power of the experience.

In modern western culture, he says, hallucinations suggest “madness or something dire happening to the brain”—even though most hallucinations stem from other causes. Consequently there is stigma. Patients often keep quiet about hallucinations for fear that their doctors, family and friends will question their sanity.

In fact, a bewilderingly enormous range of medical, biochemical, neurological, physiological and pharmaceutical influences can trigger hallucinations—perceptions that arise in the absence of an external reality. To illustrate, Sacks summons forth a long parade of patients who have, as medical narrative traditionally prescribes, only a first name…or perhaps a last name that consists of a single letter.

Meet Rosalie, a blind woman in her 90s with no mental impairments. She suddenly began to “see” people wearing Eastern robes marching solemnly, silently, up and down stairs. Some had bizarrely misshapen faces. Animals accompanied others.

The staff at her nursing home first called a psychiatrist, but later called Sacks for his opinion. He determined Rosalie had Charles Bonnet Syndrome, a condition affecting the brain’s visual system—a syndrome not well known, but apparently not uncommon among older people who lose their eyesight. Some people with CBS, named for 18th-century Swiss naturalist Charles Bonnet, may also hallucinate letters or musical notes.

Meet Ray P., a triathlete. Ray hallucinated during physical exhaustion: “Once, I was competing in the Ironman Triathlon in Hawaii. I was not having a good race, I was overheated and dehydrated—miserable. Three miles into the marathon portion of the race, I saw my wife and my mom standing on the side of the road. I ran over to them to say I would be late to the finish line, but when I reached them and began telling my tale of woe, two complete strangers who did not even remotely resemble my wife and mother looked back at me.”

An entire spectrum of visions arises from migraine—not the headache, but the cascading waves of electrochemical brain activity that may precede the headache or arrive independently of it altogether. Sacks himself has these hallucinations. He relates how he saw his first vision when he was only 3 years old—dazzling, shimmering, zigzagging colored light. It became an enormous arc from ground to sky.

Sacks says neuroscientists increasingly suspect that patterns seen in migraine hallucinations reflect something about the “self-organizing activity in vast populations of visual neurons.” These “geometric hallucinations of migraine allow us to experience in ourselves not only a universal of neural functioning, but a universal of nature itself.”

We also find sensory deprivation among the myriad conditions that trigger hallucinations. Think of the isolation tanks popularized in the 1950s and ‘60s…and portrayed to the point of caricature in the movie Altered States.

Hallucinations may include imaginary smells and taste and the altogether common hallucination of hearing one’s name spoken from across a room or street. Sacks cites a 1973 paper, controversial at the time, in which eight people with no mental problems presented themselves at hospitals, admitting to “hearing voices.” Doctors diagnosed all as schizophrenic, with one being held two months.

“Psychiatry, and society in general, had been subverted by the almost axiomatic belief that ‘hearing voices’ spelled madness and never occurred except in the context of severe mental disturbance,” Sacks writes. (Perhaps the same experiment would turn out differently today, as psych wards empty out and jails fill up with people having chronic mental illnesses—a subject for another book.)

It turns out that Parkinsonism itself can trigger hallucinations.

Meet Tom C., an artist who complained of “misperceptions,” not wanting to call them hallucinations. “His first misperception occurred when he was in a nightclub; the skin of the other dancers, even their faces, seemed to be covered with tattoos. At first he thought the tattoos were real, but they started to glow and then to pulse and writhe; at that point he realized they must be hallucinatory. As an artist and psychologist, he was intrigued by this experience—but frightened too, that it might be the beginning of uncontrollable hallucinations of all sorts.”

Medicine has recognized epilepsy for centuries as a bringer of visions. Jen W. told Sacks that, beginning at age 4, she saw “a ball of colored lights on the right side, spinning, very defined.” It spun for several minutes before being replaced by a gray cloud. Later in life, after a grand mal seizure, doctors diagnosed an “epileptic focus” in her left occipital lobe. Once they removed the lobe, the visions stopped—for a while anyway. A blind spot remained in the lower right quadrant of her visual field.

This gets to another of Sacks’ points—that modern medicine has an increasing ability to link particular hallucinations to specific parts or processes of the brain.

On and on go the causes: phantom limbs, hallucinated by amputees; delirium tremens in alcoholics; tactile hallucination; dysosmia, or imaginary smells, associated with herpes simplex; polyopia and palinopsia, with multiple images spread over space and time; macropsia, micropsia and all manner of other maladies.

Then, in the middle of these conventionally “scientific” observations, comes a chapter on drugs—and Sacks’ own account of his years as a grad school dope fiend in the 1950s and ‘60s.

While all of Hallucinations makes for engaging reading, the chapter with Sacks’ confessional clearly begs controversy. The New Yorker found it striking enough to excerpt in the August 27, 2012, issue. (Readers of the magazine could be forgiven for assuming Sacks’ personal drug experiences made up a large part of this book.)

In contrast to the purely descriptive narrative in the rest of Hallucinations, this chapter—“Altered States”—begins with a qualified justification…as if it needed some kind of apologia for being included at all. Humans, it says, need something more than day-to-day existence. “… we need to transcend, transport, escape; we need meaning, understanding, and explanation; we need to see overall patterns in our lives … We may search, too, for a relaxing of inhibitions that makes it easier to bond with one another, or for transports that make our consciousness of time and mortality easier to bear.”

Your buddy never says anything close to that when he gets wound up to tell the story that begins, “Man, this one time I got so freaking wasted…” But this chapter resembles such a tale.

Sacks’ experimentation began, of course, with much study—academic writings on the effects of cannabis, peyote, LSD and the rest. “I had done a great deal of reading, but had no experiences of my own with such drugs until 1953, when my childhood friend Eric Korn came up to Oxford. We read excitedly about Albert Hofmann’s discovery of LSD and we ordered 50 micrograms of it from the manufacturer in Switzerland…”

You could do that back then, without breaking any laws. They split the stash, took 25 micrograms each and experienced—nothing. “We should have ordered 500 micrograms, not 50,” Sacks writes.

Nine years later, his drug experiences really kicked in. He worked a neurology residency in California in 1962, just as the wave of popular American drug experimentation mounted. “Neurochemistry was plainly ‘in,’ and so—dangerously, seductively, especially in California, where I was studying—were the drugs themselves.”

He started with pot in Topanga Canyon. He took LSD and morning glory seeds. He went on to obscure substances such as Artane—a synthetic drug akin to belladonna—that produced an entire imagined breakfast conversation with a pair of friends who were, in fact, not there at all.

On a mixture of amphetamine, LSD and marijuana, Sacks saw a vision of indigo—a color he had always longed to see in its purest form. “And then it suddenly disappeared, leaving me with an overwhelming sense of loss and sadness that it had been snatched away.”

Sacks’ drug use extended all the way to an encounter with morphine. He sat motionless for more than 12 hours watching the medieval Battle of Agincourt play out in miniature on the sleeve of his dressing gown. He saw thousands of soldiers and Henry V residing in a great tent with pennants.

Another time, the withdrawal, not the drug itself, got his attention. Battling insomnia, he took large quantities of chloral hydrate to help him sleep. His stash ran out just before Christmas. In the absence of the drug, he hallucinated wildly. He feared losing his mind—he encountered a man with a “huge proboscidean head, like an elephant seal,” and subway passengers with smooth white heads like giant eggs, and faceted compound eyes like insects. A doctor friend diagnosed his trouble: “Oliver, you chump! You always overdo things,” she said. “You’ve got a classic case of the DT’s, delirium tremens.”

At one point in 1964 a friend of Sacks’ parents happened to visit in California and came away alarmed at his state of mind. “You need help Oliver,” the friend told him. “You’re in trouble.”

Writing today, Sacks seems ambivalent about his drug use. He does not say, I’m sorry I took these drugs, they wrecked my life, because clearly they didn’t. Nor does he endorse freewheeling drug use with the zeal of the ‘60s-era psychedelic apostles. He does, however, repeatedly use the word danger throughout his narrative, suggesting that he knows…and wants the reader to know…that his whole drug phase could have turned out very badly.

He does make it clear, without equivocation, that his career—his unparalleled success as a modern-day chronicler of the curiosities of the mind—owes a great deal to one particular drug binge: A weekend high on amphetamines. During that weekend, he read nonstop through a book about migraines: On Megrim, Sick Headache and some Allied Disorders: A contribution to the Pathology of Nerve Storms, a thick tome written in 1873 by a doctor named Edward Liveing. At the time, Sacks generally used speed all weekend. “I would take the stuff on Friday evenings after getting back from work and would spend the whole weekend so high that images and thoughts would become rather like controllable hallucinations, imbued with ecstatic emotion.”

On such a weekend in 1967, he opened Liveing’s book and found himself captivated. “In a sort of catatonic concentration so intense that in ten hours I scarcely moved a muscle or wet my lips, I read steadily through the five hundred pages of Megrim. As I did so, it seemed to me almost as if I were becoming Liveing himself, actually seeing the patients he described. At times I was unsure whether I was reading the book or writing it … I found myself thinking, ‘This represents the best of mid-Victorian science and medicine; it is a veritable masterpiece.’”

In his ecstasy, Sacks says he “saw migraine shining like an archipelago of stars in the neurological heavens.” And he saw something else: “Rousing myself from my reverie of being Liveing or one of his contemporaries I came to and said to myself, ‘Now it is the 1960s, not the 1860s. Who could be the Liveing of our time? … And then a very loud internal voice said, ‘You silly bugger! You’re the man.’”

The next day, Sacks returned the book to the library. Soon thereafter, he began writing his own books. And never again, he writes, did he take amphetamines.

That Sacks rooted his 1967 revelation in a literary experience was clearly significant in foreshadowing his particular success as a tour guide to the mind on the written page. While many neurologists no doubt know as much or more about the brain, very few write about it as well as Sacks. Fewer still can draw on his rich vein of literary references, from Macbeth to Melville, taking the reader beyond science itself and into all the things philosophers, novelists and poets have said about it.

He touches on Dostoyevsky’s ecstatic seizures and speculates on how they may have influenced a sense of the divine. He cites admixtures of science and literature, such as William James’ deep interest in “the mystagogic powers of alcohol and other intoxicants,” described in that author’s 1902 book The Varieties of Religious Experiences. (Sacks gives, of course, ample footnotes and a bibliography for those of a more scientific bent. If you want to know more about “Enhanced excitability of the human visual cortex induced by short-term light deprivation,” he helpfully cites work by Boroojerdi, Babak, et. al., in a periodical called Cerebral Cortex.)

Ultimately, one must wonder not only what a hallucination appears to be but what it means. Sacks offers plenty of evidence that particular hallucinations arise with particular neurochemical hiccups in particular areas of the brain.

Is that all they are? Grief-stricken, bereaved people who lose loved ones often “see” the departed. Sacks points out the work of a Welsh general practitioner who interviewed nearly 300 people who recently lost someone close. Nearly half “had illusions or full-fledged hallucinations of a dead spouse. The likelihood of such hallucinations increased with the length of marriage, and they might persist for months or even years.” The doctor considered the visions normal…and even helpful in the grief process.

James, in Varieties of Religious Experience, recounted a case history of a man who sensed a “presence”—sometimes a threatening one, but sometimes a joyful, overwhelming one, that brought a feeling of bliss. James’ subject, not a religious man, did not interpret his experiences as signifying the presence of God.

But, Sacks says, “One can readily see why others, perhaps of a different disposition might interpret the “sure knowledge of the close presence of a sort of mighty person’ and ‘a startling awareness of some ineffable good’ in mystical, if not religious terms.”

Religious delusions can be dangerous. Sacks writes of an epilepsy patient who experienced an ecstatic vision of Christ and heard a voice commanding him to kill his wife and then commit suicide. So the man killed his wife, wounded himself. He ceased having seizures after doctors removed his right temporal lobe.

Ecstatic visions can also change the world. Meet Joan of Arc, a farmer’s daughter with no formal education. She drew thousands of followers. She led a French army. She freed cities in France from English authority. Sacks writes that the evidence suggests Joan may have had—here’s that term again—temporal lobe epilepsy with ecstatic auras.

“Ecstatic seizures shake one’s foundations of belief, one’s world picture, even if one has previously been wholly indifferent to any thought of the transcendent or supernatural,” Sacks writes. “To speak of the biological basis and biological precursors of religious emotion—and even, as ecstatic seizures suggest, a very specific neural basis, in the temporal lobes and their connections—is only to speak of the natural causes.”

Wisely, Sacks concludes, “It says nothing of the value, the meaning, the ‘function’ of such emotions, or of the narratives and beliefs we may construct on their basis.”